Recently, the National Quality Forum (NQF) endorsed a set of preferred practices for palliative and hospice care quality and identified hospice services as a national priority area for healthcare quality improvement. The preferred practices, however, were primarily identified through expert opinion and there have been no national studies linking use of hospice preferred practices with patient outcomes and hospice costs. A critical barrier to continued progress in the field is building the evidence base for the NQF preferred practices, as this proposal seeks to do. The Specific Aims of this longitudinal study are: 1) Determine the association between hospice preferred practices (e.g., 24-hour crisis management phone access, more frequent pain and symptom management practices) and hospital utilization by patients receiving hospice care, including intensive care unit and emergency department admissions, and hospital versus home death; 2) Determine the association between hospice preferred practices (e.g., an ethics committee, interdisciplinary team meetings that include nurses, social workers, physicians and chaplains, more frequent pain and symptom management practices) and hospice disenrollment and hospice length of stay; and 3) Examine the impact of hospice preferred practices on hospice costs. Until now, such a study was not feasible because we lacked national data on the use of preferred practices by hospices; however, Dr. Carlson's recent work conducted through her National Institute of Nursing Research K99/R00 collected and examined data from the National Hospice Survey, which surveyed a national random sample of hospices (N=591, 84% response rate) regarding their use of patient-centered and family- centered NQF preferred practices. The aims of this proposal will be accomplished by linking the National Hospice Survey data to Medicare claims data for patients newly enrolled by hospices following the survey completion date and to hospice costs reports. We will employ hierarchical generalized linear models to test the associations between hospice preferred practices and outcomes, accounting for patient, hospice, and county level covariates. The proposed project is innovative in using the first, detailed national data on the use of preferred practices by hospices and linking these data to patient outcomes and hospice costs. The multidisciplinary research team assembled by Dr. Carlson has the background and expertise to successfully complete this project. The contribution of this study will be significant because it will identify the specific hospice practies that most strongly relate to patient outcomes and hospice costs. Such information may guide national recommendations on best practices and will inform regulatory and professional interventions to monitor and promote higher quality, more cost effective care at the end of life in the hospice setting.